Provider Demographics
NPI:1801312640
Name:KONDOUCH, YAROSLAV
Entity type:Individual
Prefix:
First Name:YAROSLAV
Middle Name:
Last Name:KONDOUCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 FRIAR DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-5520
Mailing Address - Country:US
Mailing Address - Phone:440-864-0986
Mailing Address - Fax:
Practice Address - Street 1:20600 CHAGRIN BLVD STE 620
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5340
Practice Address - Country:US
Practice Address - Phone:216-751-4762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.378568163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult